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Wednesday, May 30, 2012

For Transplant, Smoker's Lung Beats No Lung

By Michael Smith, North American Correspondent, MedPage TodayReviewed by Robert Jasmer, MD; Associate Clinical Professor of Medicine, University of California, San Francisco and Dorothy Caputo, MA, BSN, RN, Nurse Planner.

Patients who need a lung transplant are better off receiving organs from a deceased smoker than staying on the waiting list, British researchers reported.

They will not live as long as those who get lungs from non-smokers, but they will outlive patients who stay on waiting lists, reported Robert Bonser, MD, of the University Hospitals Birmingham NHS Trust in Birmingham, England.

The issue has been controversial in Britain after media reports of death following transplantation of lungs from smokers, the researchers reported online in The Lancet.

But the policy of using such lungs saves lives and "should be continued," Bonser and colleagues concluded after studying outcomes of 1,295 lung transplants from July 1, 1999 to Dec. 31, 2010.

The U.S. also uses lungs from smokers, according to Norman Edelman, MD, chief medical officer for the American Lung Association. He told the Associated Press that most donated organs have some defect and a history of smoking is just another factor that needs consideration.

"There is rarely an 'ideal' organ available," Edelman said.

On the other hand, the balance of risks can vary from country to country and center to center, argued Marcelo Cypel, MD, and Shaf Keshavjee, MD, both of the University Health Network in Toronto.

In an accompanying comment article, they added that the damage to donor lungs caused by smoking can be "quite variable" and it might be that only lungs from a subgroup are causing the lower survival rates after transplant.

"By contrast," they argued, "unaffected lungs from donors with positive smoking histories could potentially lead to similar outcomes to those noted in patients receiving lungs from non-smoking donors."

That issue was not addressed in the study, they noted.

Based on data from the U.K. Transplant Registry and Office of National Statistics, Bonser and colleagues reported, there were 2,181 people registered on the waiting lists during the 11.5-year study period and 1,295 lung transplants (880 double and 415 single) from 1,221 donors.

Of those, 510 -- or 39% -- used lungs from donors who had smoked.

The key finding was that recipients of such lungs had worse three-year survival than those who got lungs from non-smokers (adjusted HR 1.36, 95% CI 1.11 to 1.67, P=0.003).

On the other hand, of 2,181 patients on the waiting list, 802 (or 37%) died or were removed from the list without receiving a transplant, Bonser and colleagues reported.

The figures yielded a lower unadjusted hazard of death after registration for those who accepted lungs from smokers than for those who remained on the waiting list (HR 0.79, 95% CI 0.70 to 0.91,P=0.0004).

The effect was even more pronounced for recipients suffering from septic lung disease and fibrosis, where the hazard ratios were 0.60 and 0.39, respectively.

Bonser and colleagues noted that donors with a history of smoking account for 39% of the lungs available for transplant in the U.K. "Rejection of this donor-organ resource would increase waiting-list mortality and is ill-advised," they argued.

One consequence of using lungs from people who had smoked is that the risk and benefits need to be carefully explained to recipients, they cautioned.

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